State laws, rising threats have chilling effect on transgender care

[August 25, 2023]  By Daniel Trotta

(Reuters) - A Massachusetts healthcare center that provides gender-affirming care says it has allocated hundreds of thousands of dollars to protect its staff and patients, amid a rise in threats and harassment against some treatment facilities in the United States.

The center, which asked not to be identified to avoid attracting further aggression, said it raised $261,000 from five grants to put a security system in place to deal with menacing phone calls, harassment and the potential for more serious threats. It is planning to spend $98,000 a year on security going forward.

"We could be caring for 2,000 patients or more, at the very least, with that money," said the center's chief executive, who requested anonymity to speak freely without compromising security or attracting trolls.

Massachusetts is not among the 20 states where legislatures with Republican majorities have banned or restricted treatments such as puberty blockers, hormone therapy or surgery for transgender minors.

But the political climate driving the legislation is having a chilling impact beyond those 20 states and on patients older than 18, according to more than a dozen care providers and transgender advocates across the country.

They described a rise in threats against several treatment centers in different parts of the country, including harassing and bigoted phone calls and online messages, as well as clinics stretched thin in more welcoming states by an influx of patients from jurisdictions where treatment is restricted.

"You're having effects not just in states that have banned gender-affirming care, but also in other states that are afraid of protests," said Marci Bowers, president of the World Professional Association for Transgender Health (WPATH), which helps establish treatment standards for gender-affirming care.

Several of the legislative bans have been blocked in court, offering at least temporary protection for patients but also fueling uncertainty about what remains permitted at any one time, clinicians said.

"It's confusing to physicians. It's confusing to patients and their families," said Jesse Ehrenfeld, president of the American Medical Association, which represents physicians and medical students across the United States. "It's completely inappropriate that you've got lawmakers inserting themselves into medical decision-making."

In Florida, Senate Bill 254, enacted in May, banned gender-affirming care for minors but also created less-noticed barriers for adult care. One provision requires that only physicians administer puberty blockers and hormones, instead of the nurse practitioners and physician assistants who typically provided such care.

The law also requires the physician be present in the same room as the patient, eliminating most virtual appointments.

Seventy clinics, representing one-fourth of the 271 specializing in gender-affirming care in the 20 states that have enacted restrictions, have closed since the bans began in 2021, according to a July 25 research letter in the Journal of the American Medical Association (JAMA).

Some 43% of transgender adults have considered moving because of anti-LGBTQ legislation in their state, according to a survey by the liberal think tank Data for Progress. Another 8% said they have already moved.

For some transgender people, the combination of the political discourse and social pressure feels overwhelming.

"It really made us feel not welcome. We looked at it and we're like, okay, there's a target on us," said Rylee Brock, a 30-year-old trans woman who moved to Champaign, Illinois, from Omaha after the Nebraska legislature banned surgery for transgender minors. "In Omaha, I couldn't be myself, except in very safe spaces."

Transgender youth may adopt a specific name and pronouns and undergo psychological counseling as part of their transition. The state laws largely intervene to stop gender-affirming medical care around adolescence: treatments such as puberty blockers, hormones and later, in rare cases, surgery.

Medical consensus favors gender-affirming care as essential and sometimes life-saving, after careful consideration by multiple providers. The American Medical Association, the Endocrine Society, the American Academy of Pediatrics and many other medical associations endorse it.

Some parents and professionals have raised concerns that youth are being rushed into treatment, while critics and supporters alike say more research is needed.

The state legislative response has been to ban such care for minors, providing a rallying point for conservative politicians and organizations.

A number of them also oppose recognition of transgender identity through bathroom bills and bans on student athletes joining sports teams that do not align with their assigned sex at birth.

Legislation that has banned gender-affirming care for transgender youth in 20 states has reverberated beyond the borders of those 20 states and infringed on patients older than 18, showing the far-reaching impact of the political climate that is driving such bans. In this photo, protesters rally for the International Transgender Day of Visibility in Tucson, Arizona, U.S., March 31, 2023. REUTERS/Rebecca Noble/File Photo

Gary Click, an Ohio representative who sponsored a gender-affirming care ban that passed the Ohio House in June and is now before the state senate, said he wants to protect minors from the side effects of medical treatments, especially those that they may later regret.

He said extremists who threatened clinics were motivated for their own reasons, unrelated to legislation like his. But he also said gender-affirming medical treatments were extreme.

"I am totally against extremism," Click said. "I think extremism begets extremism. I'm trying to be that level-headed person that comes in and says, 'Listen, let's look at the science.'"

EXTREMISM ON THE RISE

The FBI and U.S. Department of Homeland Security identified a rise in "domestic violent extremism" from individuals who have easy access to guns and a list of perceived grievances related to race and gender, in their annual threat assessment report to Congress in June.

The Massachusetts health center said one member of its team was "doxxed" about six months ago by having a home address and cellphone number published, which generated harassing calls and online posts.

Boston Children's Hospital said it endures "daily threats and challenges," including from multiple callers opposed to its Gender Multispecialty Service (GeMS) program, one of which resulted in a federal indictment against a Massachusetts woman.

"Boston Children's has been subjected to bomb threats, protests, governmental inquiries, and direct threats to individual clinicians," the hospital said in a statement to Reuters.

Another Boston clinic, part of the renowned Fenway Institute, received a threatening, expletive-laden telephone call that resulted in federal charges against a Texas man.

The FBI said it "takes all potential threats seriously" but declined to address specific investigations. The Boston Police Department and the Massachusetts State Police did not respond to requests for comment.

Colorado Children's Hospital said threats against other children's hospitals providing gender care drove it to reduce its online publicity about transgender service to protect staff.

Colorado has not enacted restrictions on gender-affirming care. But the hospital, which generally serves patients up to the age of 22, said it has stopped providing surgery for adult patients because of "unprecedented referrals for gender-affirming care."

The LGBTQ health advocacy group GLMA said clinics in states such as Colorado, Illinois, New York, California have been "absolutely inundated" since other states started banning care. It did not provide specific figures on referrals.

San Francisco surgeon Thomas Satterwhite, who has been doing gender transition surgery on minor and adult trans patients for nine years, said his practice, Align Surgical Associates, paused public comments on its social media accounts because of a surge in bigoted comments around last November's midterm elections.

Satterwhite said one out-of-state patient who recently came to his clinic quizzed him about Align's security protocols and a young medical professional whom he met at a conference and had trained in gender care was now considering another field, he said. That person declined to be interviewed.

ADULTS AFFECTED, TOO

The Florida law's mandate that "only a physician" may administer treatments or prescriptions for adults, affected clinics that rely largely on nurse practitioners and physician assistants, providers said.

Joseph Knoll, CEO of Spektrum Health, a nonprofit specializing in care for LGBTQ patients, said his clinics in Orlando and Melbourne have turned away more than 100 adults and minors since the ban was enacted.

Plume Health, a virtual gender-affirming care clinic that operates in 45 states, said it responded to Florida's restriction on virtual care with temporary "pop-up" in-person clinics, staffed by physicians.

The non-profit Orlando clinic 26Health clinic said it stopped providing gender-affirming care after the law was enacted for fear of losing their license and having to close their doors to their nontransgender patients.

"It is appalling, quite frankly, that we are targeting individuals who are already vulnerable and marginalized," said Syvonne Carter, chief executive of 26Health.

(Reporting by Daniel Trotta; editing by Donna Bryson and Suzanne Goldenberg)

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